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Current definition and explanatory notes: Increased daytime frequency, that is frequent urination during the day, as going constantly and having to go too much.(Koyne KS 2010), less than 2 hours (Koyne 2012). Symptoms need to be defined as ‘subjectively relevant’ when the patient regarded the symptom as at least ‘quite a problem’, 'some bother’ and ‘much/major bother’ (Haltbakk 2005). One of the challenges to this term and to the use of nocturia is that they are patient complaints and we recognize that an individual may not have the perspective to realize what is the normal frequency of micturition during the day, unless they have had a recent change in these symptoms. Individuals tend to define normative experiences based on their own environments and if a woman has a sister and a mother who have urinated 16 times/ day for as long as she can recall and she voids this often she would not think to complain about increased daytime frequency. Certainly this can be later defined as a signby the clinician, but shouldn’t this be qualified as a symptomby the professional collecting this history?

Old definition: Increased daytime frequency is the complaint by the patient who considers that he/she voids too often by day.This term is equivalent to pollakisuria used in many countries.
Mechanisms: The factors taken into consideration when determining when and where to void are poorly understood; afferent outflow originates from discrete systems (pain, stretch receptors, urothelial-dependent mechanisms and a motor/sensory system) and that bladder sensations are contained within this ‘ afferent noise ’ (Gillespie 2009, de Groat 2009, Fowler 2008, Birder 2007); afferent noise increases progressively as the bladder fills.

Therapies: Regardless of conservative treatment, the main class of drugs for managing the symptom has been the anticholinergic/antimuscarinic medications (Thüroff 2011). The most common deficiency of these agents is their side-effect profile, which include increased risk of dry mouth and constipation, aggravation of narrow-angle glaucoma, and a potential impact on cognition in the elderly. None of the commonly used antimuscarinic drugs (darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine, and trospium) are an ideal first-line treatment for the symptom. Optimal treatment should be individualised, considering the patient’s comorbidities and concomitant medications and the pharmacologic profiles of different drugs (Chapple 2008). Mirabegron is a β3-receptor antagonist, the first in a new class of agents developed for the treatment of OAB; it has direct impact on this condition by causing relaxation of the detrusor muscle; the drug can also reduce the sensation of urgency (Nitti 2013). Overactive bladder/idiopathic detrusor overactivity inadequately managed with antimuscarinics have been considered for treatment with botulinum toxin: the dose of > 100 U provided a meaningful and sustained benefit, with the exception of the 200-U dose, which was sometimes the outlier (Fowler 2012), with improvements in HRQOL scores; there were drops out of treatment (approximately 60%), mainly as a result of CIC related issues or UTI; many of the patients had reverted back to conservative treatments and antimuscarinic therapy to which they were initially refractory (Mohee 2013).
Perspectives and controversies:Studies on bladder sensations, obtained during cystometry or from voiding diaries, are proving difficult to transfer to everyday experiences; there is therefore a need to explore what does influence when and wheretovoid; many voids are driven by behavioural factors not by sensations of desire or need to void. The prevalences of OAB increase with advancing age, and the rapid increase of an aged population is associated with tremendous cost; the prevalence and socioeconomic costs are higher than osteoporosis, chronic obstructive pulmonary disease, cerebrovascular accident, and diabetes mellitus. An effective rescue or policy might be considered for these future socioeconomic costs.

Resources and references
  • K. S. Coyne, C. C. Sexton, Z. Kopp, C. R. Chapple, S. A. Kaplan, L. P. Aiyer, T. Symonds. Assessing patients’ descriptions of lower urinary tract symptoms (LUTS) and perspectives on treatment outcomes: results of qualitative research. Int J Clin Pract, 64 (9): 1260–1278, 2010
  • K. S. Coyne, A. I. Barsdorf, C. Thompson, A. Ireland, I. Milsom, C. Chapple, Z.S. Kopp, T. Bavendam. Moving Towards a Comprehensive Assessment of Lower Urinary Tract Symptoms (LUTS) Neurourology and Urodynamics 31:448–454, 2012
  • J. Haltbakk, B. R. Hanestad, S. Hunskaar: Relevance and variability of the severity of incontinence, and increased daytime and night-time voiding frequency, associated with quality of life in men with lower urinary tract symptoms.BJU Int 9 6: 83–87; 2005
  • Gillespie JI, van Koeveringe GA, de Wachter SG, de Vente J. On the origins of the sensory output from the bladder: the concept of afferent noise . BJU Int 103: 1324 – 1333, 2009
  • de Groat WC , Yoshimura N . Afferent nerve regulation of bladder function in health and disease . Handb Exp Pharmacol 194: 91–138, 2009
  • Fowler CJ, Griffiths D, de Groat WC . The neural control of micturition . Nat Rev Neurosci 9: 453–466, 2008
  • Birder LA, de Groat. Mechanisms of disease: involvement of the urothelium in bladder dysfunction. Nat Clin Pract Urol 4: 46–54, 2007
  • Harvey J, Finney S, Stewart L, Gillespie J.The relationship between cognition and sensation in determining when and where to void: the concept of cognitive voiding. BJU Int 110: 1756-1761, 2012
  • Thüroff JW, Abrams P, Anderssonc KE, Artibani W, Chapple CR, Drake MJ, Hampel C, Neisius A, Schröder A, Tubaro A. EAU Guidelines on Urinary Incontinence. Eur Urol 59: 387–400, 2011
  • Chapple CR, Khullar V, Gabriel Z, Muston D, Bitoun CE, Weinstein D. The effects of antimuscarinic treatments in overactive bladder: an update of a systematic review and meta-analysis. Eur Urol 54: 543–62, 2008
  • Nitti VW, Khullar V, van Kerrebroeck P, Herschorn S, Cambronero J, Angulo JC, Blauwet MB, Dorrepaal C, Siddiqui E, Martin NE. Mirabegron for the treatment of overactive bladder: a prespecified pooled efficacy analysis and pooled safety analysis of three randomised, double-blind, placebo-controlled, phase III studies. Int J Clin Pract.;67(7):619-32.
  • Fowler CJ, Auerbach S, Ginsberg D, Hale D, Radziszewski P, Rechberger T, Patel VD, Zhou J, Thompson C, Kowalski JW. OnabotulinumtoxinA Improves Health-Related Quality of Life inPatients With Urinary Incontinence Due to Idiopathic Overactive Bladder: A 36-Week, Double-Blind, Placebo-Controlled,Randomized, Dose-Ranging Trial. Eur Urol 62 (2012), 148–157
  • Mohee A, Khan A, Harris N, Eardley I. Long-term outcome of the use of intravesical botulinum toxin for the treatment of overactive bladder (OAB). BJU Int. 2013; 111(1):106–13

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